Healing the Mind Body Connection, LLC

Name

Address

Street Address Line 2

CityState

Zip

DOB

Phone

Format: (000) 000-0000.

Email

example@example.com

Occupation

Is this your 1st facial?

How did you hear about us?

How often do you receive facials?

What is your goal for today's service?

Are you claustrophobic?

Are you sensitive to heat on your face?

Do you wear sunscreen daily?

Does your job or daily activities require you to be in the sun most of the day?

Are you pregnant?

Are you past your 1st trimester?

Do you have migraines, headaches, sinus issues? (Check all that apply)

Are you currently under the care of a dermatologist?

If yes to the above, what are you being treated for?

Do you experience discomfort or unease when your face is touched?

Do you have a sensitivity to heat?

List of medications and health conditions

Please describe your skin type/condition:

Do you have any open sores, wounds or infections on your face or upper chest area?

Have you had any chemical peels, hair removal, Botox, laser treatments, or microdermabrasion recently in the last month?

If yes to the above, please explain:

Have you used or currently using any of the following in the pat three months?

Are you currently using any acne medications?

If yes to the above, explain:

Do you have any allergies:

Other

Have you ever had an allergic reaction to any of the following? If yes, please specify (Check all that apply)

IF THERE ARE CONTRAINDICATIONS THAT MAY PREVENT YOU FROM RECEIVING THIS SERVICE, ALTERNATIVES MAY BE AVAILABLE IF THE SERVICE CAN STILL BE PERFORMED SAFELY. IF THE ALTERNATIVES CANNOT BE PROVIDED, YOU WILL BE INFORMED BEFORE THE SESSION.

RELEASE AND CONSENT FOR MASSAGE SERVICES:

I understand that the basic facial massage treatment I am receiving is intended primarily for relaxation and the relief of muscle tension. If I experience any pain, discomfort, or allergic reaction during this session, I will immediately inform the practitioner so that the pressure and/or products can be adjusted to my comfort level. I release Healing the Mind Body Connection, LLC, and the practitioner from any responsibility or liability related to my participation in these sessions. I agree not to hold Healing the Mind Body Connection, LLC, or the practitioner liable in the event of any injury or aggravation of a pre-existing condition.

CLIENT SIGNATURE

DATE

Date

Consent to Treatment of Minor: By my signature below, I hereby authorize Healing the Mind Body Connection, LLC. to administer therapeutic massage to my child or dependent as they deem necessary.

Parent or Legal Guardian

DATE

Date

Healing the Mind Body Connection, LLC

Basic Facíal Massage Intake Form

Your Skin